Cavernous carotid aneurysms in the era of flow diversion: a need to revisit treatment paradigms.

BACKGROUND AND PURPOSE: Recent techniques of endoluminal reconstruction with flow-diverting stents have not been incorporated into treatment algorithms for cavernous carotid aneurysms. This study examines the authors' institutional experience and a systematic review of the literature for outcomes and complications using the Pipeline Embolization Device in unruptured cavernous carotid aneurysms. MATERIALS AND METHODS: A retrospective search for cavernous carotid aneurysms from a prospectively collected data base of aneurysms treated with the Pipeline Embolization Device at our institution was performed. Baseline demographic, clinical, and laboratory values; intrainterventional data; and data at all follow-up visits were collected. A systematic review of the literature for complication data was performed with inquiries sent when clarification of data was needed. RESULTS: Forty-three cavernous carotid aneurysms were included in the study. Our mean radiographic follow-up was 2.05 years. On last follow-up, 88.4% of the aneurysms treated had complete or near-complete occlusion. Aneurysm complete or near-complete occlusion rates at 6 months, 12 months, and 36 months were 81.4%, 89.7%, and 100%, respectively. Of patients with neuro-ophthalmologic deficits on presentation, 84.2% had improvement in their visual symptoms. Overall, we had a 0% mortality rate and a 2.3% major neurologic complication rate. Our systematic review of the literature yielded 227 cavernous carotid aneurysms treated with the Pipeline Embolization Device with mortality and morbidity rates of 0.4% and 3.1%, respectively. CONCLUSIONS: Endoluminal reconstruction with flow diversion for large unruptured cavernous carotid aneurysms can yield high efficacy with low complications. Further long-term data will be helpful in assessing the durability of the cure; however, we advocate a revisiting of current management paradigms for cavernous carotid aneurysms.

Life stage, substance use and health decline in a community cohort of urban African Americans.

This longitudinal study analyzed chronic health effects, predominantly somatic, resulting from substance use in a homogeneously urban African American community cohort (n = 411). Individual and collective effects of eight licit and illicit substances on change in perceived health (index of reported health conditions formulated as regressed change scores) were tested as the cohort matured into young adulthood. Ten additional measures of health behavior, social attainment and social networks were introduced to control against spurious causal attribution. Gender differences in direct and intercorrelated drug effects and their timing processes were observed. Substance use explained a larger share of the variance in men's health than in women's. In absolute numbers of health problems, however, substance use had a greater effect on women's health.

Changing HIV infection rates and risk in an African-American community cohort.

This longitudinal study of a homogeneously urban African-American community cohort drawn from the metropolitan New York area (USA) analyzed three-year change in HIV-1 antibody prevalence and self-reported risk practices separately for men and women. Specifically, risk practices reported on personal interviews and results from blood sero-assay in 1989-1990 were compared to similar interview reports of risk practices and HIV assay from saliva samples in 1993. Results showed: (1) women's infection rates increased more than men's, resulting in a male to female infection ratio of 1.5:1; (2) heterosexual transmission accounted for most of women's new infection; (3) in multivariate analysis, multiple partners was a significant heterosexual risk indicator for both men and women, increasing infection odds five-fold; and (4) buying sex also increased heterosexual men's infection odds approximately five-fold. Results document increasing rates of African-American HIV infection linked largely to heterosexual exposure risk, that the African-American male-female infection ratio resembles the global rather than North American one, and also the utility of an expanded classification of heterosexual exposure risk.

HIV-1 seroprevalence and risk behaviors in an urban African-American community cohort.

OBJECTIVES: Previous attempts at obtaining population estimates of human immunodeficiency virus type 1 (HIV-1) seroprevalence have been beset by problems of cooperation bias. As part of the fourth round of study with an urban African-American community cohort, the following investigation was aimed at assessing HIV-1 prevalence and the relative importance of sex and drug injection as risk factors in infection. METHODS: Personal interviews were conducted in the home with 364 respondents, followed by voluntary blood sample collection from 287 of these individuals. RESULTS: Blood assays showed a point prevalence of 8.4% HIV-1 seropositivity in this community cross section, with a higher female-to-male ratio than appears among acquired immunodeficiency syndrome (AIDS) case reports. Most infected persons were unaware and unsuspecting of their infection. CONCLUSIONS: First, findings underscore the need to focus on risk behaviors rather than on risk groups. Second, the smaller than 2:1 ratio of infected men to women suggests that current AIDS case reports seriously underestimate HIV-1 infection among certain cohorts of African-American women. Finally, widespread ignorance of own infected status and inaccurate risk assessment signal the substantial task for community health educators in reaching inner-city African-American men and women at risk.

Health and substance use behavior: the longitudinal Harlem Health Study.

Described here is a 22 year prospective study of adolescents focusing on health problems, substance use and other health behaviors, and treatment needs of urban African Americans. The study panel was drawn from a probability sample of households in Central Harlem (NYC). Accordingly, it is a community representative sample comprised about equally of males and females. Data from the study have been used for planning the local municipal hospital's adolescent service and for informing drug policy and community education activities regarding trajectories in and out of drug use. Given the timing of the research, the latter has focused chiefly on heroin and polydrug use. Current investigation focuses on drug use and sexual practice as risk behavior in HIV infection. In the report which follows, requirements and procedures in sample retention are emphasized, since epidemiological research is valid only to the extent its population representativeness is maintained. Major findings regarding health and substance use trajectories over three data collection time points are discussed.

Health through three life stages: a longitudinal study of urban black adolescents.

This is a study of life stage coherence and change in perceived health status and morbidity reports over a 15 year interval bounding adolescence. Data were obtained through personal home interviews with a representative sample (N = 426) of urban black youths who were interviewed at three successive life stages: first when they were adolescents ages 12-17, 6-8 years later when they were ages 18-23, and 7-8 years after that when they were ages 26-31. Results showed that health decline was neither continuous nor progressive over the three life stages. Instead, a dramatic increase in morbidity reports occurring between adolescent and post adolescent measurement was succeeded by stabilization in the following 7 year interval. One interpretation of these findings is that they reflect the stressfulness of the adolescent life stage in the urban black youth cohort. The congruence of this interpretation with Mechanic and Angel's theory of differential health synchrony over the life course and also with Antonovsky's theory of sense of coherence in explaining variations in perceived health is discussed. The study, finally, pointed up a serious methodological impediment to attempting comparative life span health studies such as this, namely, the difficulty in arriving at equivalently comprehensive and sensitive health symptom indicators at different life stages.

Heroin availability and aggregate levels of use: secular trends in an urban black cohort.

The influence of heroin availability on the aggregate level of use of this drug was investigated for a normal Black cohort (born between 1952 and 1957) who grew up in Harlem (New York City). Data obtained on the second and third waves of a panel study were used to estimate annual rates of heroin initiation and cessation from the mid-1960s through 1983. The aggregated time-series variables indicated that initiation into heroin use was largely confined to adolescence and that cessation rates exhibited substantial year-to-year fluctuations with no apparent relationship to either chronological age or calendar year. Respondents born before 1955, however, had much higher rates of heroin use than those born in later years. Temporal trends in initiation and cessation were uncorrelated with changes in the purity of heroin sold in New York City between 1973 and 1983, suggesting that aggregate levels of heroin use in this sample were little affected by changes in supply. More speculatively, cohort differences in lifetime prevalence may reflect varying availability at the times younger and older cohorts entered adolescence. This possibility could not be directly tested because of the absence of reliable purity data going back sufficiently far in time.

Drugs, lifestyle, and health: a longitudinal study of urban black youth.

The association of drug use with indicators of health status was studied in a representative sample of urban Black youth interviewed first in adolescence and then six to seven later in young adulthood. Seven substances, with interaction terms as appropriate, were tested against a psychophysical health scale and also against a more inclusive general health scale. Both measures of health outcomes yielded similar findings. Earlier inhalants use and, under certain conditions, methadone were linked to health change in males. Heroin had a delayed relationship to females' health. Additionally, methadone was associated with poorer health among young Black women who also were heavy alcohol drinkers. The observed relationships between drug use and health persisted after introducing controls for associated lifestyle factors.

Pathways to heroin abstinence: a longitudinal study of urban black youth.

Reported here is a study of the effectiveness of treatment in reducing the duration of heroin careers, with a special focus on gender differences. The longitudinal research is based on a community representative sample of urban black youth, ages 18-23, and utilizes a recently introduced statistical methodology, event-history analysis. Simple hazard probability analysis confirmed that males and females did not differ significantly in their cumulative probabilities of abstinence from heroin. The more elaborated event-history model demonstrated, however, that treatment played a significantly different role among young men and women in attaining abstinence. While a man's likelihood of abstinence was but marginally greater with treatment than without it, women's likelihood of abstinence was significantly increased by entering treatment.

Dealing with drugs: heroin abuse as a social problem.

Reported here are attitudes and perceptions regarding heroin control, prevention, and treatment obtained in a survey of community leaders in four high drug traffic and drug use neighborhoods in New York City. Studies in the past have focused on the causes and consequences of heroin use primarily from the standpoint of the drug user. Operationalizing the tenet that heroin abuse is a social problem, this study develops an ecological paradigm for analyzing the effects on neighborhoods of illicit drugs and of prevention, intervention, and treatment policies. The research was undertaken in 1981 for the New York State Heroin and Alcohol Study Commission. It demonstrates the importance of including community perspectives in policy decisions and the usefulness of a study group of community leaders as a reliable source of this information.

Causal factors in onset of adolescents' cigarette smoking: a prospective study of urban black youth.

This research is based on a two-wave panel study of 536 urban black adolescents. Six to eight years intervened between measuring the predictors and measurement of subsequent smoking initiation. Separate prediction models were tested for males and females, based on a multivariate causal model which spanned five domains of prior conditions: personal background, school achievement, family-peer orientations, psychogenic orientations, health attitudes and behaviors. Variables from all five domains influenced subsequent smoking but different predictors were implicated for adolescent males vs. females. This lends support to one of the major hypotheses in this research--that the salient experiences which governed the decision to start smoking were different for black males and females. Applying the same prediction model to cigarette smoking and to illicit drug involvement showed no overlap in prediction for males and but two of the same influences to be significantly implicated in females' illicit drug use and cigarette smoking.

Health stability and change: a study of urban black youth.

Personal interviews were conducted with a representative sample of 536 urban Black youth at two points in their life cycle: first when they were adolescents, aged 12--17, and six to eight years later when they were young adults, aged 18--23. A total of 47 health problems for males, 48 for females, were inquired about each time. Longitudinal analysis was performed to determine the extent of change, the direction of change, and the health problems most subject to change. The number of health problems increased for both sexes, but the increase was significantly greater among males than females. Male and female morbidity count, thus, became nearly equivalent in young adulthood whereas, in adolescence, young women's had exceeded men's. More detailed age analysis revealed that the greatest increase in male's health problems occurred two years behind that for women: for men, between ages 17 and 18; for women between ages 15 and 16. With but few exceptions, the same health problems which dominated in adolescence continued to be most prevalent in young adulthood. Population prevalence rates, however, understate the considerable degree of shift or turnover in individual cases reporting health problems as well as in general health status as measured by the total number of those problems.

Indicators of health status in adolescence.

The study reported here is based on data obtained in 1968-1970 from a representative community sample of urban black youths in the United States aged 12-17 years, inclusive. Analysis is directed at conceptual and methodological issues in measureing health status. It suggests the need for greater attention to subjective self-evaluated self-reported components of health status, specified here as "ontological" health. This is related to health and illness behavior generally, to utilization of health services more particularly. The case is made for a multiple-indicator approach to measuring health status as being more consistent with the multidimensional phenomenon to which it refers. The method used in this study for deriving a composite health status index from four component self-reported indicators is described. The distribution of the sample on this composite was used to identify self-reported health conditions that warrant attention from providers of adolescent health services. Since subjective evaluations influence experienced severity of health problems, the health status composite index was applied in this study as a means of discriminating differntial seriousness in self-reported health problems. Finally, some differences between indications of "ontological" health and "medical" health also are analyzed for commonalities and differences between them.

Dentist's ratings and adolescents' perceptions of oral health.

The extent to which adolescents' self-appraisals of dental status agree with the dentist's evaluation is analyzed. The dentist's evaluation was expressed in standard dental status indicators (DMF, OHI-S, Russell Index) and in a rating of overall status as "excellent," "good," "fair," "poor." The relationship between the adolescents' self-reported dental care practices and the dentist's evaluation is also examined.